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Mt. Hood Disability Services: Student Accommodation Request Form

STUDENT NAME:   DATE:  
TERM: Fall Winter Spring Summer YEAR:
COURSES SECTION INSTRUCTOR

*SKD10 MUST BE APPROVED EACH TERM. PLEASE DISCUSS THIS WITH YOUR SKD10 FACILITATOR*

* I WANT THE SAME ACCOMMODATIONS I HAD LAST TERM*

Or

I WOULD LIKE TO ADD THESE ACCOMMODATIONS:
Approval for accommodations not previously requested must be arranged through the DSO Coordinator via telephone (503-491-6923); fax (503-491-7549); email (dsoweb@mhcc.edu); or a meeting
APPROVED

                                                                              STUDENT ID NUMBER:    
Student Signature
TO BE COMPLETED BY DSO STAFF
Instructor Notification Form(s)
Completed
Date:            
Delivered to Instructor: Date:            
Fax (503) 491-7549
                                                         
  DSO Staff Signature
   
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